Provider Claims Specialist I: Resolve High-Value Claims & Appeals

Inland Empire Health Plans; California; On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical, Dental, Vision

Life insurance and disability

Career advancement

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) option with match

Pet care insurance

Job summary

Inland Empire Health Plans is seeking a Claims Specialist I - Provider Claims to evaluate and process professional and institutional medical claims under the supervision of the Provider Claims Resolution & Recovery Supervisor. The role emphasizes determining coverage and payment levels while handling provider disputes and appeals with timely resolution letters.

Ideal candidates bring four years of experience in claims evaluation, proficiency in ICD-10 and CPT coding, and strong analytical,

Qualifications

• Four years of experience evaluating and processing institutional and professional medical claims.
• Proficiency in medical claims system, ICD-10 and CPT coding.
• Experience with provider disputes, appeals and claim adjustments.
• Experience in HMO/Managed Care setting preferred.
• Medicare and/or Medi-Cal experience preferred.

Responsibilities

• Evaluate professional, high-dollar and outpatient/inpatient institutional claims and determine coverage and payment levels.
• Resolve provider disputes and appeals; issue resolution letters.
• Process adjustment requests timely and accurately per standard procedures.
• Participate in payment adjustment projects and complex claims as assigned.

Skills

Claims processing

ICD-10 coding

CPT coding

Data analysis

Excel

Regulatory compliance

Communication

Education

High School Diploma

Tools

Microsoft Office

Excel

Job description

Inland Empire Health Plans is seeking a Claims Specialist I - Provider Claims to evaluate and process professional and institutional medical claims under the supervision of the Provider Claims Resolution & Recovery Supervisor. The role emphasizes determining coverage and payment levels while handling provider disputes and appeals with timely resolution letters.

Ideal candidates bring four years of experience in claims evaluation, proficiency in ICD-10 and CPT coding, and strong analytical,